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Continuous Subcutaneous Opioid Infusion (10.12)

Continuous Subcutaneous Opioid Infusion (10.12) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Medications

10.12

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
December 18, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 10.12 A

Original
Revision

Page
1
of 5

Title: Continuous Subcutaneous Opioid
Infusion (Adult)

I. PURPOSE

To initiate, discontinue and maintain a continuous subcutaneous opioid infusion.

II. POLICY

The dose and rate of a continuous subcutaneous opioid infusion is ordered by the
physician, the appropriate solution is prepared by the pharmacist, and the infusion is
initiated and monitored by the registered nurse.

III. EQUIPMENT

A. Non-sterile gloves to be worn by all personnel starting or discontinuing parenteral
devices
B. MiniMed® Sof-set subcutaneous needle (CS Item Number #1216552)
C. Lockable analgesic infusion pump (Alaris® PCA module and Alaris® Point of
Care Unit)
D. Alaris® infusion pump and administration set
E. Subcutaneous solution as prescribed
F. Tape
1. Use transparent adhesive dressing, or, if the patient is sensitive to these,
adhesive or non-allergic tape
G. Skin preparation
2. ChloraPrep® applicator (2% Chlorhexidine and 70% isopropyl alcohol)
H. If two sites will be used due to subcutaneous infusion rate greater than 2-3 mL/hr,
extension set bifuse connector (CS Item Number 4014051), two male-male
adapters and one female-female adapter (stored in the Nurse Manager’s office on
inpatient Hematology, Oncology and BMT Unit) are needed to connect the
subcutaneous needles to the IV infusion.

IV. PROCEDURE

A. Place Subcutaneous Needle and Initiate Infusion
1. Acknowledge the physician's order in the patient’s clinical record for
prescribed solution, volume, additives, and rate of flow.
2. Determine if the patient has any allergies (sensitivities) to medication,
chlorhexidine, tape, etc.
3. Order a lockable analgesic infusion pump (Alaris® PCA module and Alaris®
Point of Care Unit) and gather other supplies as needed.

Page 2 of 5

a. Because medication solution used is highly concentrated, it is essential to
use an infusion pump capable of delivering 0.1 mL increments. Select the
appropriate therapy from the Alaris® Guardrails drug library.
b. If the patient is admitted with a rented infusion pump from an outside
vendor, this pump should be replaced with the currently approved UWHC
infusion device and the patient should be instructed to store their rented
pump at home until it is needed again at time of discharge from the
hospital.
c. Obtain prescribed solution, and perform an independent double-check as
defined in UWHC Hospital Administrative Policy 8.33, High Alert
Medication Administration.
4. Perform hand hygiene according to UWHC Hospital Administrative Policy
13.08, Hand Hygiene.
5. Connect the administration set to the solution container. Prime the tubing set
with solution then load the tubing into the pump when using the Alaris®
System. (If using another delivery system, prime and load following the
instruction booklet accompanying each pump.) Attach the subcutaneous
needle to the end of the tubing, and flush with solution.
6. Select site for placement of subcutaneous needle.
a. A single subcutaneous infusion site can usually accept up to 2-3 mL per
hour. If the infusion must run at a rate of greater than 2-3 mL/hour two
subcutaneous infusion sets should be branched to infuse into two sites.
These sites can be placed as close as two inches apart.
b. If two sites are needed, either two separate pumps must be used or an
extension set bifuse connector (CS Item Number 4014051), two male male
adapters and one female-female adapter subcutaneous needles to the IV
infusion.
c. Any area with a layer of subcutaneous fat is potentially available as an
infusion site. However, consideration should be given to the patient's
preferred lying positions and fat distribution. If there are no
contraindications, choose one of the following four sites: left and right,
between the breast and the clavicle; or right or left on the abdomen. See
Figure 1.

Page 3 of 5


d. Other sites, such as the upper arms or thighs or the upper buttocks, may
also be appropriate if they fit the individual patient's needs. If these
exceptions are to be utilized, document the reason why.
7. Remove excessive hair with clippers if indicated. Perform hand hygiene
according to UWHC Hospital Administrative Policy 13.08, Hand Hygiene
8. Follow instructions for placement of Medtronic MiniMed® Sof-set for
Subcutaneous Infusions in the related section of the policy on U-Connect.
9. Cover the infusion site with a transparent adhesive dressing. Place the date
and time on the dressing. Anchor the infusion set with tape if the patient
prefers tape or is sensitive to transparent adhesive dressing. The infusion site
should be left as visible as possible to allow for frequent checks for redness,
swelling, or leakage.
10. Make a loose loop of infusion tubing and anchor with tape. If tension is
applied to the tubing, it is absorbed in the taped loop.
11. Document in the clinical record:
a. Solution type and additives
b. Resulting concentration of medication per mL
c. Initial infusion rate and dose
d. Placement site and site assessment
B. Site and Infusion Maintenance
1. The RN is responsible for maintaining the rate of flow as ordered.
a. Check infusion site a minimum of one time each shift for redness,
swelling, or leakage. Change the infusion site to the next planned location
should any of these occur. Check the site more frequently (every 4 hours)
if an infusion site is receiving more than 2 mL per hour. Poor absorption
of fluid and medication is more prone to appear when an infusion site
delivery rate approaches or surpasses 2 mL per hour, or in the presence of
inflammation.

Page 4 of 5

2. Change the infusion site every 72 hours or sooner if it develops any redness,
leakage, or swelling.
a. If there are no contraindications, rotate clockwise around these four sites:
left and right, between the breast and the clavicle; followed by right then
left on the abdomen (see Figure 1).
b. Other sites, such as the upper arms, upper thighs, or the upper buttocks
may also be appropriate if they fit the individual patient's needs. If these
exceptions are to be utilized, document the plan for their use and rotation.
If possible, include at least four distinct sites in any plan for rotation to
ensure that each site has adequate time to rest and heal between uses.
3. Change administration set and Y extension set with every site change.
a. Most infusion sites will last 2-3 days. If the infusion site surpasses 3
mL/hour, the extension set bifuse connector (CS Item Number 4014051),
two male-male adapters and one female-female adapter (stored in the B66
{inpatient Hematology, Oncology and BMT Unit} Nurse Manager’s
office) are needed to connect the subcutaneous needles to the IV infusion..
These sites can be placed as close as two inches apart, but place further
apart if tubing length and patient anatomy allows.
b. As the dosage nears the 2 mL/hr limit for each site, consider obtaining
order to change to a more concentrated solution.
C. Monitoring/Documentation
1. RN will monitor and document according to policy
a. Routine periodic site care is not required for subcutaneous catheters unless
the dressing has become soiled, wet, or loose.
b. Palpate the site routinely through the dressing for evidence of heat or
tenderness.
c. Visually inspect for erythema, swelling, or drainage around the dressing.
d. Document assessment results in the Lines/Drains/Airways section of the
patient’s clinical record.
D. Discontinue Site and Infusion
1. To discontinue infusion:
a. Determine whether patient will continue to require alternative analgesia
after the pump is discontinued.
b. If the patient is to receive an oral opioid, give the first scheduled dose one
hour prior to stopping the infusion.
c. Turn off pump and discontinue site as below.
d. Waste any remaining drug per Pharmacy Policy 7.9, Disposal of
Controlled Substances. It is essential that the solution be removed from the
pump before it is returned to Central Services.
e. To discontinue site:
i. Turn off pump. Loosen tape, and pull the infusion set straight out
with a swift motion. Hold a 2x2 gauze over the site with pressure
for 30 seconds. Check site, and if there is leakage of fluid, repeat
the pressure until the site is dry. There is no need to dress the site if
the skin is intact.
E. Discharge Planning
1. At least 2 days prior to discharge, determine whether the infusion will be
continued at home.

Page 5 of 5

2. If the patient will be discharged on a non-parenteral form of analgesia, discuss
with the attending physician and the Case Manager whether the patient will
require ongoing monitoring from a home health agency. Make referrals as
appropriate.
3. If the patient will be discharged on a continuing infusion, contact Chartwell at
831-8555, at least two days prior to discharge. They will arrange for a pump
or another vendor and/or continuing home health or hospice services as
appropriate to the patient/family needs and insurance requirements.

V. RELATED RESOURCE

Applied Medical Technology Ltd (2008). Using the Medtronic Minimed Sof-Set®.
See Related Resources section on U-Connect.

VI. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 8.33, High Alert Medication Administration
B. Hospital Administrative Policy 13.08, Hand Hygiene
C. Pharmacy Policy 7.9, Disposal of Controlled Substances

VII. REFERENCES

A. Anderson, S. L., & Shreve, S. T. (2004). Continuous subcutaneous infusion of
opiates at end-of-life. Annals of Pharmacotherapy, 38(6), 1015-23.
B. Chaiyakunapruk, N., Veenstra, D. L., Lipsky, B. S., & Saint, S. (2002).
Chlorhexidine compared with povidone-iodine solution for vascular catheter-site
care: a meta-analysis. Ann Inter Med, 136(11), 792-801.
C. Koshy, R. C., Kuriakose, R., Sebastian, P., & Koshy, C. (2005). Continuous
morphine infusions for cancer pain in resource-scarce environments: comparison
of the subcutaneous and intravenous routes of administration. Journal of Pain &
Palliative Care Pharmacotherapy, 19(1), 27-33.
D. Mikkelsen, L. P., Butler, J., Huerta, D., Tsals, I., Davidson, D., & Hamm, S.
(2000). A pharmacokinetic and tolerability evaluation of two continuous
subcutaneous infusions systems compared to an oral controlled-release morphine.
Journal of Pain & Symptom Management, 19(5), 348-56.

VIII. REVIEWED BY

Clinical Nurse Specialist, Adult Pain
Nursing Education Specialist, Oncology
Nursing Patient Care Policy and Procedure Committee, November 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer